D Heimer, SM Scharf, A Lieberman and P - Thaiwonders

Sleep apnea syndrome treated by repair of
deviated nasal septum
D Heimer, SM Scharf, A Lieberman and P Lavie
Chest 1983;84;184-185
DOI 10.1378/chest.84.2.184
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Sleep Apnea Syndrome Treated by Repair of
Deviated Nasal Septum*
Dov Heimer, M.D.; Steven M. Scharf M.D.; Alberto Lieberman, M.D.;
and Peretz Lavie, Ph.D.
Sleep apnea syndrome (SAS) often presents a difficult
therapeutic problem to the clinician since many of the
accepted modes of therapy are associated with only partial
success or with a number of long-term complications. We
present three patients with obstructive SAS in whom dramatic
clinical improvement occurred following repair of a
deviated nasal septum. The subjective improvement was
associated with a diminution in the number and duration of
obstructive apnea episodes as observed during a standard
sleep study. Because ofits simplicity and low rate of complication,
we propose that repair of a deviated nasal septum be
further evaluated as a mode of therapy for this condition.
Sleep apnea syndrome (SAS) is characterized by
recurrent apnea during sleep, primarily during
stages 112 in non-REM sleep. The apnea lasts more
than 10 seconds and occurs more than 30 times per
sleep period.’ Clinically, there is heavy snoring during
sleep, excessive daytime somnolence, decreased intellectual
capacity, and in approximately half the cases,
obesity. There are three types of apnea: central, in
which all breathing eflbrts cease; peripheral, in which
breathing efforts continue, but air flow ceases as a
result ofupper airway obstruction; and mixed, in which
central-type apnea evolve into the obstructive type.
The apneic episodes are often associated with hypoxemia
and arousals. ‘Theatment modalities include:
weight loss,2 tracheostomy to bypass the upper airway
obstruction,’ and respiratory stimulants such as progesterone,4
and protryptyline.’ However, there are
major difficulties with each ofthese modes of therapy.
Weight loss by diet is often unsuccessful because of
poor patient cooperation. Long-term tracheostomy is
fraught with complications,6 and drug therapy is at best
only partially successful.4” Thus, alternate modes of
therapy must be sought.
We present three patients with documented SAS in
whom dramatic clinical improvement occurred followmg
repair of a deviated nasal septum. This clinical
improvement was associated with a decrease in the
number and duration ofapneic episodes measured in a
standard sleep study.
MATERIALS AND METHODS
Whole night polysomnographic recordings were performed in the
conventional way. Variables measured included EEG, electrooculogram,
and electromyogram (recorded from the sternocleidomastoid);
the sleep periods were seven hours. Sleep stages were
scored according to standard criteria.7 Respiratory movements were
detected by the use ofa strain gauge respiratory belt tied around the
Fmm the Division ofLung Diseases, and Department ofEar Nose
and Throat, Soroka Medical Center, and Faculty of Health
Sciences, Ben Gurion University of Negev, Beersheba, and Sleep
Laboratory, Technion, Haifa, Israel.
Manuscript received December 6; revision accepted March 28.
lower thorax, and air flow at the nose and mouth was detected by use
of nasal and oral thermistors.
Each patient underwent a complete ear, nose, and throat examination.
The extent ofobstruction to the nares was estimated clinically.
Nasal septal repair was done by a standard submucosal resection
performed under local anesthesia.
All patients underwent lung function testing including measurements
of forced expiratory flows, lung volumes, and ventilatory
responsiveness to CO,.
CASE 1
A 56-year-old man of European extraction was referred to the
pulmonary clinic because ofcontinually falling asleep at his job and
loud snoring at night. Physical examination revealed: weight-.ll0
kg, approximately 80 percent obstruction of the right nostril by a
deviated septum, and a normal cardiopulmonary system. Pulmonary
function testing was normal. A sleep study revealed approximately
300 episodes of apnea with an average duration of 25 sec. Approximately
60 percent of the apneas were peripheral. The patient was
unable to follow a weight reduction diet. A six-week trial of therapy
with medroxyprogesterone acetate (80 mg a day in four divided
doses)failed tolead to clinical improvement. Fullpatencyofthe right
nostril was restored following repair of the deviated septum. The
patient noticed a marked clinical improvement in his symptoms with
almost complete disappearance of his daytime somnolence. Repeat
sleep study eight weeks fullowing surgery showed that the number of
apneas was now 106 per sleep period with an average duration of 15
sec. At the time of his sleep study he was receiving no medication
and his weight was unchanged.
CASE 2
A 44-year-old man of North African origin presented to the
pulmonary service complaining of excessive daytime sleepiness.
Because of the frequent napping, he was forced to quit his job as a
construction worker. He also had loud nightime snoring, and
impotence. Physical examination revealed: weight-119 kg, complete
obstruction ofthe left nostril, and a normal cardiopulmonary system.
Pulmonary function testing was normal. The patient could not follow
adiet, and an eight-week trial ofmedroxyprogesterone(80 mg/day in
four divided doses) failed to lead to clinical improvement. Sleep
study revealed 290 apneas per sleep period with an average duration
of 25 sec, 80 percent of which were peripheral. Following submucosal
resection of the deviated septum, examination revealed
nearly complete patency ofthe left nasal passage. Within two weeks
of surgery, the patient noted a marked diminution of the daytime
somnolence. A repeat sleep study done six months following surgery
showed that the number ofapneas per sleep period had decreased to
184 Sleep Apnea Syndrome and Deviated Nasal Septum (Helmarat a!)
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40 with an average duration of 15 sec. By that time, the patient
resumed a normal working life and his sexual function had returned.
His weight remained essentially the same as at the initial examination
and he was taking no medications.
CASE 3
A 40-year-old diabetic man ofNorth African origin was referred to
the pulmonary service because of severe nighttime snoring, and
excessive daytime sleepiness to the point ofinterfering with his work
as a glass worker. Examination revealed: weight, 70 kg; complete
obstruction ofthe left nostril; and a normal cardiopulmonary system.
Sleep study showed 350 apneas per sleep period with an average
duration of 40-50 sec, all of which were peripheral. Within two to
three weeks following submucosal resection of the septum, the
patient noted dramatic diminution in his daytime somnolence.
Repeat sleep study performed 12 months following surgery showed
dramatic improvement with only 40 apneas per sleep period, most of
which were central. At the time ofthe repeat sleep study, his weight
was 71 kg and the patient was receiving no medication.
A further point of note is that all three of these patients were
observed to be nasal breathers on the sleep examination as shown by
the pattern ofair flow in the nasal and mouth thermistors.
DISCUSSION
The three SAS patients described here responded
clinically and objectively to repair of a deviated nasal
septum. It should be noted that none ofthese patients
complained ofobstructed breathing or any other nasal
symptoms. In two, weight loss and treatment with
medroxyprogesterone acetate was unsuccessful. There
are a number of reports in the literature describing an
association between upper airway obstruction and
breathing disturbances during sleep. Nasopharnygitis
in children, for instance, is associated with an increase
in the frequency and duration of apneic spells during
sleep.8 Simons et al9 described a case of hypersomnia
associated with nasal septal deviation which was successfully
treated with submucosal resection. However,
data from a post-surgery sleep study were not provided.
The same authors also reported that repair of
the nasal septum did not improve the condition of
three other patients’#{176} suffering from SAS. Several
authors have found that sleep disturbances occur in
normal subjects following temporary occlusion of the
nares. Zwillich et al” demonstrated a decrease in the
depth ofsleep and an increase in the number of apneic
episodes with complete nasal occlusion. Lavie et al”
showed an increase in the number of microarousals
associated with nonapneic breathing and an increase in
the amount of awake time during the sleep period of
subjects under these circumstances. Data from the
same laboratory’3 also demonstrated that in two-thirds
of their sleep apneic hypersomnolent patients, physical
examination revealed an upper airway abnormality
(nasal septal deviation, hypertrophy of the adenoids,
etc). Several of these patients, ie, those suffering from
hypopneas during sleep, improvement in symptoms
and sleep study was noted following nasal septal repair.
Regarding the mechanism of improvement in SAS
following repair of the nasal septum, there are at least
two possibilities: upper airway obstruction could lead
to apneas via disturbed reflex mechanisms, possibly
trigeminally or vagally mediated, which normally act
to preserve airway patency in the presence of negative
pressure in the upper airway;’4 and direct mechanical
effects-with obstruction of the upper airway the
pressure gradient for airflow increases and the pressures
within the upper airway become more negative
relative to atmospheric. This could lead to a greater
tendency for airway closure. Ifthis were the case, then
it would be expected that a nasal as opposed to oral
breathing pattern would predispose to the development
of apnea during sleep. All three of our patients
demonstrated nasal breathing during their sleep studies,
which is consistent with direct mechanical effects
as being the mechanism of production of apneas.
A potential advantage of repair of a deviated nasal
septum in the treatment of SAS is its very low rate of
complication and it can be performed under local
anesthesia. Furthermore, even partial success may be
worthwhile and obviate the need for other modes of
treatment. On the basis ofour observations, therefore,
we recommend that repair of a deviated nasal septum
should be further evaluated as a form oftherapy in the
treatment of symptomatic sleep apnea syndrome.
REFERENCES
1 Guilleminault C, ‘fllkian A, Dement WC. The sleep apnea
syndrome. Ann Rev Med 1976; 27:465-84
2 Fairman RP, Sugerman HJ. Gastroplasty for obstructive SAS and
morbid obesity. Am Rev Respir Dis 1982; 125:108 (suppl)
3 GuilleminaultC, Simmons B, MottaJ, CurnmiskeyJ, Roskind M,
Schroeder J, et al. Obstructive SAS and tracheostomy. Arch
Intern Med 1981; 141:985
4 Sulton FD, Zwillich CW, Creagh CE. Progesterone for out
patient treatment of Pickwickian syndrome. Ann Intern Med
1975; 83:476-79
5 Conway W, Roth T, Zonick F Protryptyline therapy for upper
airway sleep apnea. Am Rev Respir Dis 1982; 125:102 (suppl)
6 Conway WA, Victor LD, Donald J, Magilligan J, Fugita S, Zorick
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7 Rechtchaffen A, Kales A. Manual of standardized terminology,
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8 Steinschneider A. Nasopharyngitis and prolonged sleep apnea.
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9 Simons FB, Hill MW. Hypersomnia caused by upper airway
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10 Simons FB, Guillerninault C, Dement WC, ‘.fllkian A, Hill N.
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12 Lavie P, Fischel N, Jomer J, Eliaschar I. The effect ofpartial and
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13 Lavie P, AIroy G, Halpern E. Apneic and non-apneic breathing
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14 Mathew OP, Abu-Osba YK, Thach BT Influence ofupper airway
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CHEST I 84 I 2 I AUGUST, 1983 185
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Sleep apnea syndrome treated by repair of deviated nasal septum
D Heimer, SM Scharf, A Lieberman and P Lavie
Chest 1983;84;184-185
DOI 10.1378/chest.84.2.184
This information is current as of April 20, 2008
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